How and When to File an Appeal

You must submit an internal appeal to us within 180 days of receiving the adverse benefit determination. All internal appeal requests must be in writing, except for an internal appeal request involving urgent care, which may be requested in writing, verbally or electronically.

All internal appeal requests must include the following information:

• • 1. The covered person’s name and identification number as shown on the ID card;
    2. The provider’s name;
    3. The date of the medical service;
    4. The reason you disagree with the coverage denial; and
    5. Any documentation or other written information to support your request.

Mail your request to:

If we approve your appeal request, we will provide you, your doctor or ordering health partner with the appropriate notice. If we deny your internal appeal of an adverse benefit determination, we will notify you with a final adverse determination notice. 

Expedited Review of Internal Appeal 

You may request an expedited internal appeal of an adverse benefit determination for certain health care services and treatment. If you have questions about this process, please see your Evidence of Coverage or call Member Services.

We will complete an expedited review of an internal appeal of an adverse benefit determination as soon as possible given a member’s medical needs, but not later than 72 hours after we receive the request.

Review of Other Decisions

You or your authorized representative may also request a review of any decision that does not involve an adverse benefit determination. These types of decisions may cover:

• The availability, delivery or quality of health care services;
• Claims, payments, handling or reimbursement for health care services; or
• Matters involving the contractual relationship between the member and the plan.

Additional Help

If you have questions about your rights or need help, please refer to the Evidence of Coverage for your CareSource plan or call Member Services at the number below.